Electronic Supplementary Material
ICM-2011-00584.R2
ESM 1: PICC Insertion and Maintenance
PICC lines were inserted at the bedside by the vascular access team using sterile precautions and a comprehensive prevention program or rarely by interventional radiology if bedside insertion was unsuccessful or inappropriate. Catheters were 5 French (F) or 6F polyurethane, double-lumen (18 gauge/18 gauge) power PICC lines (Bard Access Systems, Salt Lake City, UT). No catheters contained anti-thrombotic, antibiotic, or antiseptic material. Real-time ultrasound, standardized maneuvers, and a modified Seldinger technique were used for insertion. All patients received a chest x-ray to confirm placement, followed byapplication of a catheter stabilization device. The vascular access team routinely followed all patients, obtained surveillance chest x-rays when lines appeared manipulated, reviewed daily chest x-rays when done, and adjusted or replaced all catheters that were not in optimal position. Catheters were routinely flushed with heparin unless a heparin allergy existed. Our ICU used the following measures for all patients with PICC lines: 1) A sequential compression device was placed on the forearm on the side of the PICC; 2) range of motion was performed every 2 hours on the upper extremity with the PICC; 3) pulsed infusion technique and “clamping” the PICC near the end of the flush; and 4) only 10-cc syringes were used to flush the line.
ESM 2: Definitions and Rationale for Explanatory Variables
Hereditary thrombophilias were diagnosed whenever there was a history of protein C or S deficiency, activated protein C resistance, antithrombin deficiency, increased levels of Factors 8, 9, 11, hyperhomocysteinemia, or prothrombin gene 20210A mutation. Acquired thrombophilia was diagnosed in patients with anti-phospholipid syndrome. Other variables of interest included age, sex, ethnicity, tobacco use, obesity, port thrombosis requiring thrombolytic instillation, administration of estrogen, antiplatelet agents, coagulopathy (prothrombin time > 12.5 or partial thromboplastin time > 32 seconds), mannitol, vancomycin, statins, and hypertonic saline, based on theory or previous literature suggesting an association with PRLVT. Mannitol was documented when more than one dose was given and was administered in 0.25-1.0g/kg intravenous boluses over 10 minutes every 4 to 6 hours to maintain serum osmolality of 310-320 mOsm/kg.
ESM 3: Data on Surgical Procedures Longer than 1 Hour
Among the 99 patients who underwent a surgery longer than 1 hour during dwell time of the catheter, 102 neurosurgical procedures and 21 non-neurosurgical procedures were performed. Neurosurgical procedures consisted of 65 craniotomies or craniectomies, 21 angiographic procedures performed under general anesthesia, 5 wound revisions, 1 carotid endarterectomy, and 10 spine surgeries. Non-neurosurgical procedures consisted of 18 surgical tracheostomies, 2 orthopedic, and 1 abdominal surgery. Only 6% of surgeries required a blood transfusion.
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